New Gouverneur Hospital SNF

In the surveyor’s words

From the most serious findings on record at New Gouverneur Hospital SNF, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jul 27, 2026

  Based on observation, staff interviews, and record review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) in a timely manner to an unresponsive resident who had full code status. This was evident in one (Resident #3) of three residents sampled for cardiopulmonary resuscitation. Specifically, on [DATE] at approximately 6:40 PM, staff entered Resident #3's room without emergency medical equipment after being alerted by a family member that the resident was unresponsive. Registered Nurses #11 and #12 failed to initiate any emergency response and action. As a result, approximately 15 minutes had passed before cardiopulmonary resuscitation was initiated, and ultimately, Resident #3 expired at 7:22 PM. […]

• No harm, potential for more than minimal, patternF656Oct 18, 2022

  Based on observations, record review and interviews conducted during the Recertification survey from 10/12/22 to 10/18/22, the facility did not ensure person-centered Comprehensive Care Plans (CCP) were developed and implemented for each resident to address the resident's needs. This is evident in 4 (Resident #s 93, 202, 222, and 184) out of 38 sampled residents. Specifically, there was no documented evidence 1) a CCP related to limited range of motion was developed for Resident #93, 2) a CCP related to side rail (SR) use was developed for Resident #202, 3) a CCP related to respiratory care was developed for Resident #222, and 4) a CCP related abuse prevention was developed for Resident #184. […]

• No harm, potential for more than minimal, isolatedF609Jul 27, 2026

  Based on interviews and record review, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment are reported to the New York State Department of Health (NYSDOH). This was evident in one (Resident #3) out of three residents sampled for Abuse. Specifically, the facility failed to report an incident involving a delay to initiate cardiopulmonary resuscitation for Resident # 3 that resulted in death. The facility investigated the incident but did not report it to the New York State Department of Health. […]

• No harm, potential for more than minimal, isolatedF656Dec 19, 2024

  Based on record review and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure a comprehensive person-centered care plan was developed for each resident, that includes measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs. This was evident in 1 (Resident #20) of 38 total sampled residents. Specifically, a care plan for a diagnosis of Major Depressive Disorder and the use of antidepressant medication was not developed for Resident #20. […]

• No harm, potential for more than minimal, isolatedF657Dec 19, 2024

  Based on record review and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that a resident's comprehensive care plan was reviewed and revised to reflect the resident's status. This was evident in 1 (Resident #217) of 8 residents reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, Resident #217's comprehensive care plan was not revised to accurately reflect the resident's mode of transfer. […]